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Managing Chronic Pain and Fatigue

The key to reducing pain is reducing inflammation.

Thanksgiving 2019. Andrea Klockow of Alpharetta, Georgia, notices the middle finger on her right hand looks really “creepy” – like a sausage. Fortunately, it goes away, and Klockow doesn’t give it much more thought.

Over the next four months, though, she starts struggling with overwhelming fatigue, sore fingers and pain in her ankles and knees. “My joints, particularly the joints in my fingers, hurt the most,” 36-year-old Klockow recalls.

March 2020. Klockow makes an appointment with a rheumatologist, who does bloodwork. It comes back inconclusive. No indication that Klockow has any kind of inflammatory disease.

Summer 2020. Klockow’s scalp begins to itch so badly that it wakes her up from a deep sleep. “I couldn’t see what was going on with my scalp, but I suspected something was up because I have always been a very sound sleeper,” she says. Klockow knows not to take all these symptoms lying down, so back to the rheumatologist she goes. This time, the rheumatologist suspects Klockow has psoriatic arthritis (PsA) and suggests she see a dermatologist.

The dermatologist examines Klockow, looks at her scalp and puts her on a biologic, which works like a charm for her itching. “Within 10 days of my first injection, I was starting to feel great,” Klockow says. The biologic doesn’t help the joint pain as much right away, but her doctors tell her to be patient. With time, it will help her PsA as well, they say. They turn out to be right about that too. “Now I have all my energy back, and my joints don’t hurt,” Klockow says happily.

PsA Can Cause Chronic Joint Pain

PsA is a chronic disease characterized by arthritic inflammation of the joints, including dactylitis and enthesis. Enthesitis is inflammation where tendons and ligaments connect to the bone, while dactylitis is inflammation of the small joints of the hands and feet. This inflammation in the hands can make fingers look like sausages, such as Klockow experienced. In addition, PsA can affect the spine, similar to ankylosing spondylitis.

About 30 percent of people with psoriasis will develop PsA. [1] According to the Joint American Academy of Dermatology/National Psoriasis Foundation [NPF] Guidelines of Care for the Management and Treatment of Psoriasis with Awareness and Attention to Comorbidities: In the vast majority of adult patients, skin manifestation of psoriasis precedes PsA, often by years. Some people develop PsA and never notice or develop psoriasis. Technically, Klockow says, she was never told she has psoriasis.

As a chronic inflammatory disease, PsA is associated with joint pain, says rheumatologist Dafna Gladman, M.D., professor of medicine at University of Toronto and senior scientist at Toronto Western Research Institute in Ontario, Canada. The joint pain from PsA is likely to be chronic unless the inflammation is controlled, Dr. Gladman says.

Some people with PsA also may have chronic pain from noninflammatory forms of arthritis such as osteoarthritis. Osteoarthritis, the most common form of arthritis, is caused by wear and tear on joints. “Osteoarthritis may actually complicate psoriatic arthritis,” Dr. Gladman says. She notes that many patients with PsA develop joint damage, which can be another cause of their chronic pain.

PsA Pain Individualized

The joint pain that PsA patients describe is very personal, according to Dr. Gladman. “For some people, it is constant and is very painful. For others, it is more annoying,” she says.

The pain of inflammatory arthritis also can be quite variable. Dr. Gladman finds that some of her patients with PsA do not complain as much about pain as do her patients with other forms of arthritis. Sometimes, though, “they develop joint deformities and damage without realizing that they have had arthritis,” she says.

Inflammatory joint pain from PsA can occur in any joint. However, most PsA patients experience it in the small joints of the hands and feet, Dr. Gladman explains, as Klockow did. “That’s followed by wrists, elbows, knees, ankles and hips,” she adds. Dr. Gladman also notes that chronic pain from osteoarthritis usually affects the large joints – knees and hips.

Because PsA is a chronic inflammatory disease, most people find their pain lessens when they move, while rest can make it worse, Dr. Gladman says. Osteoarthritis pain is the opposite: Movement makes it worse, and rest makes it better, she says.

When inflammation is the cause of PsA pain, treating it should reduce discomfort, she says. “Anti-inflammatory analgesics such as ibuprofen, naproxen and the like sometimes help,” she says. Other medications that can help include methotrexate, cyclosporine and biologic treatments.

According to a European study conducted in 2006 and cited in the joint guidelines published by AAD and NPF, people with more body surface area involvement of plaque psoriasis were more likely to acquire PsA. [2] However, some who experience both psoriasis and PsA have low body surface area involvement but many joints affected by PsA. From her experience, Dr. Gladman says, many patients “find that they’re related, but that’s not always the case.”

Treating Pain and Fatigue with PsA

Fatigue is another common symptom of PsA. “In one study of 499 patients with PsA attending the University of Toronto PsA clinic, 49 percent had at least moderate fatigue, while severe fatigue occurred in 28.7 percent,” Dr. Gladman says. [3]

Fatigue is more common in women with PsA and in patients who have a higher degree of pain, Dr. Gladman says. About 22 percent of people with PsA also have fibromyalgia. “Fibromyalgia is a condition which includes both chronic pain and fatigue,” she explains. Pain from fibromyalgia is not confined to the joints and is often described as “pain all over.”

Like joint pain, the fatigue associated with PsA is due to inflammation, Dr. Gladman says. “Fatigue will come and go with the inflammation. If fatigue is due to lack of sleep, it will improve when you get enough sleep. If fatigue is due to fibromyalgia, it may persist unless the fibromyalgia is managed appropriately,” she says. Treating fibromyalgia involves a program of medication, exercise and relaxation, she adds.

According to the joint American College of Rheumatology (ACR) and NPF guidelines for treating PsA, “It is recommended that patients with active PsA use some form or combination of exercise, physical therapy, occupational therapy, massage therapy, and acupuncture over not using these modalities as tolerated.”

Dr. Gladman says there is no particular diet that will decrease the inflammation that results in PsA, but if someone is overweight, he or she can feel better with weight loss.

Several Janus kinase (JAK) inhibitors in development show promise for treating pain associated with PsA, Dr. Gladman says. JAK inhibitors are a group of medications that inhibit activity and response of one or more of the Janus kinase enzymes (JAK1, JAK2, JAK3, and tyrosine kinase 2). JAK enzymes are proteins in the body that are a part of pathways that promote inflammation observed in PsA.

The joint ACR and NPF guidelines for treating PsA also point out that tumor necrosis factor alpha (TNF-a) inhibitor biologics should be used as a first-line option to treat active PsA in people who have not been treating the disease. [4] As with JAK inhibitors, TNF-a inhibitors work by neutralizing or targeting a specific pathway – in this case, the TNF-a molecule, which can cause the inflammation and pain associated with PsA.

Diagnosing and treating PsA early can help prevent or at least limit the joint damage that can occur in later stages of the disease, Dr. Gladman says.

Some PsA patients may find they need to change their medications over time in order for them to remain effective. “It really depends on the patient and that patient’s disease,” Dr. Gladman says.

PsA Treatment and COVID-19

While Klockow and others may be concerned about the immunosuppressive and/or immunomodulatory nature of their biologic or oral treatment options, current data generally suggest that such treatments do not alter the risk of contracting COVID-19, according to the NPF COVID-19 task force guidance statements. The guidance statements also recommend that patients who are not infected with COVID-19 should continue their biologic or oral therapies. Dr. Gladman suggests that people on biologics take the same coronavirus precautions as everyone else – wear a mask, social distance, etc. – and get the COVID-19 vaccine as soon as it is offered.

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References

Article References

1. Mease PJ, Gladman DD, Papp KA, Khraishi MM, Thaci D, Behrens F, . . . Alvarez D. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2013; 69(5), 729-735. doi:10.1016/j.jaad.2013.07.023.

2. Christophers E, Barker JN, Griffiths CE, et al. The risk of psoriatic arthritis remains constant following initial diagnosis of psoriasis among patients seen in European dermatology clinics. J Eur Acad Dermatol Venereol. 2010; 24: 548-554.

3. Husted JA, Tom BD, Schentag CT, Farewell VT, Gladman DD. Occurrence and correlates of fatigue in psoriatic arthritis. Ann Rheum Dis. Oct 17, 2008. PMID: 18930991. doi:10.1136/ard.2008.098202.

4. Singh, JA, Guyatt G, Ogdie A, et al. ACR/NPF guideline for the treatment of psoriatic arthritis. J Am Acad Dermatol. Jan 2019. rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf.

Author

Beth W. Orenstein

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